The American Cancer Society Cancer Prevention Study I: 12-Year Followup

Chapter 3 The American Cancer Society Cancer Prevention Study I: 12-Year Followup of 1 Million Men and Women David M. Burns, Thomas G. Shanks, Won Choi, Michael J. Thun, Clark W. Heath, Jr., and Lawrence Garfinkel INTRODUCTION The American Cancer Society (ACS) Cancer Prevention Study I (CPS-I) is the largest prospective mortality study of diseases caused by tobacco use ever conducted in terms of person-years of observation (PYO's). The study, which began in 1959 and continued through September 1972, was designed and directed by Dr. E. Cuyler Hammond (Garfinkel, 1985). The publication in 1966 of the 3-year followup of this population (Hammond, 1966) played a critical role in establishing the causal linkage between smoking and several diseases, and it remains one of the most comprehensive presentations of the disease risks caused by smoking. The ACS used 68,116 volunteers to enroll the 1,078,894 men and women in the study. The 12-year followup of this cohort, the population used in the analyses presented in this report, includes more than 11 million personyears. Previous analyses of the 12-year followup of this study were more limited in the detail presented (Hammond et al., 1977; U.S. Department of Health and Human Services, 1989); the results in this chapter represent the most complete description of the 12-year followup of this cohort reported to date. The data are presented in as much detail as possible, recognizing that a unique contribution of this study is the large number of PYO s available for analysis. Because the data cover the spectrum of tobacco-related diseases, a comprehensive description of all the findings is not feasible within the limitations of this chapter. The major focus of the chapter is to present descriptive analyses of all-cause mortality and cause-specific mortality for lung cancer, coronary heart disease (CHD), cerebrovascular disease (CVD), and chronic obstructive pulmonary disease (COPD). A more extensive presentation of cause-specific mortality is included in Appendix A. A set of detailed tables presenting the major cause mortality experience of the cohort by number of cigarettes, attained age, and duration of smoking is contained in Appendix B. METHODS Recruitment of the study population of 1,078,894 subjects was accomplished by 68,116 ACS volunteers. Each volunteer was Description of the asked to recruit about 10 households with at least one person Study Population older than 45 years of age. All household members older than 30 years were asked to complete a questionnaire. Volunteers were asked not to recruit strangers or casual acquaintances. Enrollment was completed in fall 1959. Approximately 3 percent of the questionnaires were discarded because they were incomplete or the respondents were not traced for administrative 113

Smoking and Tobacco Control Monograph No. 8 reasons. Annual followup questionnaires were collected for the first 6 years and again in 1972 for the 12-year followup. The 12-year followup includes more than 11 million PYO s. Current cigarette smokers whose data are reported in this chapter include all who answered yes to the question "Do you smoke now?," excluding those who also reported current use of pipes or cigars. Approximately 7 percent of the study population was nonwhite, and 95 percent of the subjects lived in the United States or Canada. The 25 States represented are Arizona, California, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, New York, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, and Virginia. Deaths were reported by the volunteers, and death certificates were obtained from the appropriate State health departments. Approximately 18 percent of the subjects traced died within the 12 years of followup, and death certificates were obtained in 95 percent of the reported deaths. Deaths were coded according to the Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death (World Health Organization, 1957, pp. 78-98), in a version that used two digits. The overall standardized mortality at the 12-year followup reached 81 percent of that of the United States. ANALYSIS OF CPS-I Analyses have been performed separately for white males and DATA SET white females. There were not sufficient numbers of deaths or PYO s to perform all analyses with these methods for blacks. Except where noted, data were not pooled across gender or race. Followup Most subjects were enrolled for participation during October through December 1959, although some were enrolled in early 1960. For analysis, the period of followup began July 1, 1960, allowing a period for death caused by preexisting conditions at the beginning of the study; subjects dying before July 1, 1960, were excluded. Followup surveys were conducted according to the following schedule, with questionnaires completed at the dates marked with an asterisk: September 30, 1960 September 30, 1964 September 30, 1961* September 30, 1965* September 30, 1962 September 30, 1971 September 30, 1963* September 30, 1972* When subjects were lost to followup, the last completed survey date prior to loss to followup was used as the censoring date. Date of death was taken as the first day of the month of death. Personmonths of observation (PMO's) accrued month by month until the date of loss to followup, date of death, or end of study on September 30, 1972, in which case subjects were censored alive. A maximum of 147 months of observation was accrued by participants who completed the whole period 114

Chapter 3 of the study. Deaths were tallied according to age at death, and PMO's were accrued dynamically during the period of followup across several age groups. The CPS-I data set includes information on 456,491 males, with known death dates for 117,199, and 594,551 females, with known death dates for 88,353. Descriptive Tables Analyses were restricted to never-smokers and individuals for CPS-I Data Set who smoked cigarettes only. Current cigar and pipe smokers were excluded, as were users of smokeless tobacco. Never-smokers were individuals who indicated at the time of the initial survey that they never smoked cigarettes regularly. Current smokers were individuals who indicated current cigarette smoking at the time of the initial survey. Former smokers were individuals who indicated at the time of the initial survey that they were former cigarette smokers and did not indicate current smoking at any subsequent followup surveys or who indicated that they had quit for at least 2 years on the followup surveys. Followup time for former smokers began to accrue after they had quit for at least 2 years. Age-specific PYO s and numbers of deaths for the white male and female groups separated into never-smoker, current smoker, and former smoker categories and black male and female groups separated into never-smoker and current smoker categories are presented in Appendix C. The appendix tables present deaths due to lung cancer, CHD, CVD, COPD, and all-cause mortality during the period of followup. Lung cancer deaths include lung cancer as primary, secondary (contributing cause), or tertiary (any mention on the death certificate) cause of death (code 62); the other diseases are for primary cause of death only (CHD = 00 or 01; CVD = 07, 08, 09; COPD = 3C, 34, 3D). Mortality Rate Tables 1 through 14 present mortality rates, rate ratios, and rate Ratios differences for current smokers and former smokers in comparison with never-smokers. These ratios are calculated by dividing the rate for current smokers or former smokers by the rate for never-smokers of the same age group. The rate ratio for all levels of cigarette consumption combined for a particular age group is calculated by weighting the smoking-specific rates by the PMO's for each level of consumption. Rate ratio across age groups also is presented, calcula4ed by standardization to the U.S. 1980 census population. All rates reported in this chapter are based on observed rates. Some tables for black smokers show a second set of risk estimates calculated using death rates for black smokers and white never-smokers of the same sex. Respondents whose levels of consumption were unknown are included in the calculation for combined levels of consumption. Tables 1 and 2 present risk ratio of mortality by years of duration of smoking and level of cigarette consumption. Because each level of duration has contributions from several different levels of attained age, standardization was carried out by age within each cell. Within each cell of duration by consumption, age standardization was accomplished by weighting the contribution of the age-specific never-smoker comparison group using the PMO's of the same-age smoker group; that is, rates for never-smokers were 115

116 Table 1 Mortality rate ratios for white male current smokers, by level of duration of smoking comparison never-smoker group weighted to match smoker person-years of observation for each (age x duration x cigarettes per day) cell a Duration Cigarettes Per Day 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60+ Lung Cancer 1-9 1.26 4.42 0.47 3.45 4.06 4.29 3.69 4.31 5.42 10-19 2.30 2.83 2.37 5.69 6.93 8.55 9.64 9.00 15.04 8.05 20 4.86 9.16 3.24 6.18 11.03 9.85 14.07 14.17 16.10 17.00 14.98 21-39 3.51 8.18 4.77 14.00 16.91 17.43 20.77 25.20 25.10 25.64 40+ 7.83 11.07 15.98 19.45 22.25 28.28 24.47 29.98 26.69 Combined 1.26 3.98 4.20 5.47 10.30 11.68 14.04 15.29 15.54 17.05 13.15 Coronary Heart Disease 1-9 0.89 1.21 0.73 1.18 1.43 1.37 1.25 1.32 1.31 1.24 0.99 10-19 0.75 1.44 1.67 1.96 1.88 1.75 1.74 1.52 1.48 1.52 1.14 20 1.67 1.29 1.91 2.23 2.45 2.15 1.92 1.71 1.71 1.64 1.22 21-39 1.41 0.99 2.68 2.84 2.42 2.16 2.02 1.81 1.71 1.76 1.22 40+ 5.54 0.74 3.08 3.23 3.13 2.66 2.34 1.97 1.97 1.87 1.33 Combined 1.47 1.21 1.82 2.24 2.30 2.08 1.90 1.68 1.63 1.59 1.16 Cerebrovascular Disease 1-9 1.48 0.63 1.11 0.98 0.84 1.40 1.34 1.26 1.07 0.77 10-19 1.84 1.53 1.82 1.15 1.14 1.57 1.49 1.46 1.07 0.92 20 1.36 1.48 1.67 1.46 1.69 1.76 1.61 1.61 1.19 1.00 21-39 1.93 2.40 2.15 2.02 1.78 2.24 1.87 1.81 1.18 1.09 40+ 1.71 2.64 2.26 2.64 2.28 2.41 1.57 1.74 1.26 Combined 1.57 1.28 1.74 1.51 1.62 1.85 1.68 1.56 1.18 0.96 Smoking and Tobacco Control Monograph No. 8

Table 1 (continued) Duration Chapter 3 Cigarettes Per Day 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60+ Chronic Obstructive Pulmonary Disease 1-9 3.36 2.17 3.09 9.27 8.97 12.18 11.57 8.00 10-19 3.06 5.73 4.47 5.32 7.51 8.07 11.44 13.60 10.51 20 29.95 10.76 6.86 3.60 2.69 7.45 12.92 15.23 13.80 15.47 14.96 21-39 5.69 9.28 4.07 7.22 11.94 18.73 21.34 20.75 18.40 40+ 6.23 10.99 18.92 17.44 25.56 20.51 19.33 Combined 7.50 3.30 3.59 4.59 3.67 7.03 12.15 14.01 15.42 15.47 12.98 All-Cause Mortality 1-9 0.60 1.22 0.80 1.11 1.25 1.26 1.32 1.39 1.42 1.44 1.12 10-19 0.77 1.19 1.29 1.50 1.63 1.65 1.66 1.66 1.63 1.66 1.28 20 1.24 1.02 1.41 1.73 2.05 1.96 2.04 1.95 1.92 1.83 1.48 21-39 1.20 1.01 1.66 1.98 2.17 2.23 2.25 2.15 2.21 2.17 1.71 40+ 2.37 0.73 2.04 2.44 2.78 2.71 2.63 2.56 2.38 2.21 1.81 Combined 1.01 1.07 1.37 1.72 2.00 2.00 2.03 1.94 1.89 1.81 1.40 a Within each cell of duration by consumption, age standardization was accomplished by weighting the contribution of the age-specific never-smoker comparison group using the person-months of observation (PMO's) of the same-age smoker group; that is, rates for never-smokers were standardized by age to observed smoker PMO's within each cell. 117

118 Table 2 Mortality rate ratios for white female current smokers, by level of duration of smoking comparison never-smoker group weighted to match smoker person-years of observation for each (age x duration x cigarettes per day) cell a Duration Cigarettes Per Day 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60+ Lung Cancer 1-9 0.52 1.04 1.22 0.17 1.97 1.71 1.40 0.40 1.01 10-19 2.07 2.18 2.34 2.96 3.26 4.37 3.00 3.82 7.93 20 1.55 2.01 5.87 4.41 7.09 7.05 6.75 9.23 6.41 15.55 21-39 9.99 4.88 7.27 12.25 12.35 13.08 12.30 20.43 12.32 40+ 24.15 4.29 12.27 11.16 12.75 18.92 19.37 28.26 Combined 1.63 0.89 3.00 2.91 5.00 5.21 5.72 5.63 4.81 7.73 Coronary Heart Disease 1-9 1.24 0.90 1.08 1.13 1.21 0.99 1.01 0.97 1.22 1.05 0.71 10-19 2.28 1.43 1.90 1.93 1.96 1.77 1.64 1.58 1.48 1.25 0.40 20 1.61 2.05 2.48 2.18 2.25 1.96 1.86 1.76 1.51 1.46 0.96 21-39 3.04 3.02 2.44 2.77 2.56 2.22 1.75 1.57 1.08 2.18 40+ 5.14 5.41 2.00 2.99 3.20 2.33 2.27 1.56 1.36 0.82 Combined 1.58 1.40 1.73 1.75 1.88 1.67 1.60 1.46 1.40 1.21 0.72 Cerebrovascular Disease 1-9 1.80 1.15 1.28 0.95 1.00 0.93 1.10 0.81 0.77 0.20 0.71 10-19 1.46 1.18 1.88 1.59 1.65 1.59 1.43 1.63 1.13 0.89 1.04 20 2.18 1.45 2.07 1.96 2.17 2.02 1.78 1.24 1.08 1.29 0.97 21-39 2.99 1.78 2.54 1.74 2.39 1.79 1.49 0.97 0.76 2.66 40+ 5.49 3.82 2.61 4.18 2.53 3.16 2.36 2.48 1.62 1.79 Combined 1.77 1.33 1.69 1.55 1.60 1.61 1.49 1.27 1.00 0.74 0.92 Smoking and Tobacco Control Monograph No. 8

Table 2 (continued) Duration Cigarettes Per Day 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60+ Chapter 3 Chronic Obstructive Pulmonary Disease 1-9 1.36 2.11 4.33 3.61 10-19 5.85 2.61 2.15 3.76 6.29 8.69 10.19 11.68 16.05 7.65 20 3.56 6.89 5.90 7.70 11.57 15.99 20.79 16.62 13.32 21-39 8.15 4.26 9.10 17.37 25.45 35.19 29.08 40+ 11.33 12.19 15.00 32.25 11.02 70.37 160.70 Combined 1.52 1.48 1.66 3.42 4.69 7.87 10.94 11.30 10.41 11.27 4.45 All-Cause Mortality 1-9 1.07 0.95 0.98 1.06 1.11 1.01 1.16 0.98 1.00 0.95 0.73 10-19 1.11 0.96 1.29 1.29 1.47 1.38 1.46 1.47 1.35 1.12 0.85 20 1.15 1.22 1.52 1.54 1.69 1.72 1.69 1.68 1.55 1.70 1.17 21-39 0.42 1.23 1.51 1.70 1.86 2.00 2.04 1.87 1.72 1.57 1.48 40+ 1.76 1.55 1.95 2.31 2.16 2.26 2.22 2.37 2.12 2.22 0.72 Combined 1.08 1.04 1.26 1.34 1.49 1.47 1.53 1.45 1.34 1.25 0.88 a Within each cell of duration by consumption, age standardization was accomplished by weighting the contribution of the age-specific never-smoker comparison group using the person-months of observation (PMO's) of the same-age smoker group; that is, rates for never-smokers were standardized by age to observed smoker PMO's within each cell. 119

Smoking and Tobacco Control Monograph No. 8 standardized by age to observed smoker PMO's within each cell. Respondents whose level of consumption was unknown are included in the calculation for combined levels of consumption. The rate ratios shown in these tables reflect the weighted sums across age levels within each category of duration and smoking level and, therefore, include the effect modification produced by both age and duration within any cell rather than being standardized by age to a defined population. Tables 3 and 4 present rate ratio of mortality by years of duration of cessation for former smokers by level of former smoking. The comparison never-smoker rates are age standardized within each cell to the PMO's of former smokers using the same method as in Tables 1 and 2. There were not enough black former smokers in the survey to complete these tables for blacks. Tables 5 through 10 present mortality rates and rate ratio of mortality by 15-year age groups, level of consumption, and sex and race, all standardized to U.S. 1980 population by 5-year age groups within cells. The "all-ages" value across age groups also is presented, calculated by standardization to U.S. 1980 standard population, age 30 and older. Respondents whose level of consumption was unknown are included in the calculation for combined levels of consumption. Duration-Specific The tables in Appendix B present duration-specific mortality Mortality Rate Ratios rate ratios and excess mortality rates by number of cigarettes and Attributable Rates smoked per day and attained age. These tables are calculated using modeled, rather than observed, death rates for never-smokers. Modeling of never-smoker rates was used to stabilize estimates for death rates among younger groups of never-smokers. The low numbers of deaths in age groups younger than 50 years often resulted in rates of zero or rates that were considered unstable. Modeling allowed estimation of rates for the younger age groups of never-smokers that were above zero and increased smoothly with age. Followup data were tabulated for 92,307 white male never-smokers and 375,649 white female never-smokers. Deaths were tabulated in the age group for age at the time of death. Death certificates list primary causes of death, secondary contributing causes, and underlying conditions. Lung cancer deaths were tabulated for any mention of lung cancer on the death certificate; only the primary cause of death was used to calculate death rates from CHD, CVD, and COPD. Therefore, some deaths may have been included in both lung cancer and other-cause-ofdeath categories. PMO's were accrued on a month-by-month basis to the current age group. These results allowed calculation of the rate of deaths per 100,000 person-years of observation (PYO's) (PYO's/12 = PMO's) for each age group. Never-smoker rates were modeled using both Poisson regression and linear regression of log(rate) techniques, all regressed to the median age of 5-year intervals between 40 and 85 years of age. A close fit of the data to an exponential curve was demonstrated, with close agreement between the models. Tables 1 through 5 in Appendix D show the observed death rates 120

Chapter 3 Table 3 Mortality rate ratios for white male former smokers by duration of cessation and level of cigarette consumption comparison never-smoker group weighted to match former smoker person-years of observation for each (age x duration x cigarettes per day) cell a Duration of Cessation Cigarettes Per Day 2-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 Lung Cancer 1-9 2.83 1.68 1.22 0.58 1.38 1.89 10-19 7.96 3.50 2.91 2.04 0.96 2.16 1.68 20 11.68 10.49 5.03 2.22 1.86 1.12 1.55 4.10 21-39 14.30 9.18 4.85 4.88 2.04 4.13 3.69 40+ 27.88 12.36 7.77 3.74 3.99 0.89 Combined 13.12 8.44 4.61 2.89 2.04 1.19 1.84 3.18 Coronary Heart Disease 1-9 1.55 1.36 1.38 1.08 0.71 1.01 0.83 0.46 10-19 2.53 1.56 1.26 0.93 0.93 0.92 0.77 0.62 20 3.00 1.56 1.20 1.09 0.97 0.98 1.13 0.70 21-39 2.65 2.03 1.55 1.29 1.13 1.09 0.95 0.56 40+ 2.96 1.68 1.72 1.15 1.02 0.98 1.25 0.39 Combined 2.66 1.64 1.37 1.13 0.99 0.96 0.93 0.55 Cerebrovascular Disease 1-9 1.72 1.45 1.29 1.42 0.69 0.57 0.37 0.92 10-19 1.62 1.33 1.14 0.95 0.73 0.84 0.68 0.57 20 1.33 1.05 1.03 0.95 1.17 0.84 0.79 0.58 21-39 1.46 0.75 0.90 0.76 0.53 0.56 1.58 40+ 2.27 1.41 1.05 1.23 1.36 0.90 0.97 1.23 Combined 1.62 1.16 1.05 1.01 0.93 0.78 0.80 0.65 Chronic Obstructive Pulmonary Disease 1-9 6.46 2.25 2.67 3.29 10-19 21.03 12.35 9.02 2.07 0.95 0.85 1.01 2.49 20 41.10 15.27 11.85 7.05 3.75 1.13 2.89 21-39 31.00 28.14 11.39 5.57 1.40 1.98 40+ 57.03 34.25 10.33 9.37 4.00 4.99 Combined 36.14 18.89 10.33 5.64 2.80 1.42 2.28 2.49 All-Cause Mortality 1-9 1.74 1.37 1.25 1.08 0.67 0.83 0.80 0.73 10-19 2.18 1.43 1.24 1.01 0.87 0.93 0.80 0.59 20 2.84 1.64 1.30 1.10 1.01 1.04 1.06 0.74 21-39 2.57 1.92 1.48 1.23 1.00 1.01 1.06 0.56 40+ 3.18 2.13 1.74 1.30 1.16 1.08 1.23 0.79 Combined 2.58 1.69 1.39 1.15 0.98 0.96 0.91 0.66 a Within each cell of duration by consumption, age standardization was accomplished by weighting the contribution of the age-specific never-smoker comparison group using the person-months of observation (PMO's) of the same-age smoker group; that is, rates for never-smokers were standardized by age to observed smoker PMO's within each cell. 121

Smoking and Tobacco Control Monograph No. 8 Table 4 Mortality rate ratios for white female former smokers by duration of cessation and level of cigarette consumption comparison never-smoker group weighted to match former smoker person-years of observation for each (age x duration x cigarettes per day) cell a Duration of Cessation Cigarettes Per Day 2-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 Lung Cancer 1-9 2.13 1.89 0.45 2.38 1.81 10-19 0.95 0.61 3.06 2.42 3.65 20 4.31 0.76 0.98 1.66 21-39 16.99 10.90 40+ Combined 2.85 1.51 0.58 3.19 2.52 2.61 Coronary Heart Disease 1-9 1.41 1.46 0.82 0.69 0.75 1.08 0.64 0.64 10-19 3.15 1.52 1.13 0.79 0.83 0.45 0.53 0.35 20 3.45 1.79 1.08 1.12 1.27 0.97 0.25 21-39 1.99 0.88 0.51 0.63 40+ 5.52 1.49 0.86 1.48 1.99 Combined 2.23 1.53 0.98 0.84 0.88 0.96 0.63 0.63 Cerebrovascular Disease 1-9 1.78 0.90 1.10 0.80 0.69 0.42 0.63 0.83 10-19 0.99 0.88 1.47 0.93 0.62 1.01 0.42 20 4.41 1.33 1.14 1.20 1.41 1.10 0.59 1.11 21-39 4.29 4.07 1.83 1.45 1.41 40+ 6.67 3.70 2.11 3.47 Combined 2.28 1.18 1.25 1.01 1.11 0.84 0.57 0.92 Chronic Obstructive Pulmonary Disease 1-9 16.08 5.97 4.13 8.64 10-19 3.82 4.61 5.79 4.67 20 9.52 2.91 7.35 33.48 21-39 28.31 40+ 47.91 Combined 16.08 9.46 5.15 5.45 4.67 13.74 All-Cause Mortality 1-9 1.97 1.16 1.10 0.82 0.94 0.93 0.79 0.65 10-19 1.92 1.34 1.22 0.88 0.79 0.84 0.75 0.56 20 2.84 1.53 1.18 1.16 1.22 1.33 1.17 0.52 21-39 2.87 1.27 0.95 1.08 1.36 0.60 0.87 0.95 40+ 2.56 1.67 1.50 1.26 1.29 1.75 1.09 Combined 2.17 1.31 1.15 0.94 0.98 1.02 0.88 0.63 a Within each cell of duration by consumption, age standardization was accomplished by weighting the contribution of the age-specific never-smoker comparison group using the person-months of observation (PMO's) of the same-age smoker group; that is, rates for never-smokers were standardized by age to observed smoker PMO's within each cell. 122

Chapter 3 Table 5 Mortality rates among white male current smokers, by level of cigarette consumption standardized absolute mortality rates per 100,000 a Cigarettes Per Day 35-49 50-64 65-79 All Ages Lung Cancer 1-9 7.70 46.81 168.61 59.04 10-19 11.67 103.45 367.79 122.33 20 26.46 160.73 535.38 185.63 21-39 28.29 218.18 785.54 268.71 40+ 39.71 274.33 888.75 315.26 Combined 25.16 170.95 503.51 175.87 Coronary Heart Disease 1-9 101.78 544.37 1,852.05 770.47 10-19 142.38 682.76 2,087.90 893.66 20 167.73 764.25 2,184.38 968.59 21-39 170.50 758.91 2,209.83 962.02 40+ 239.46 902.64 2,396.22 1,127.88 Combined 169.94 753.17 2,137.95 939.17 Cerebrovascular Disease 1-9 13.76 77.24 563.07 248.03 10-19 22.63 75.41 572.95 268.30 20 18.98 93.15 563.70 250.89 21-39 24.71 105.89 581.79 255.82 40+ 21.19 128.08 646.63 284.09 Combined 20.86 97.15 576.45 263.86 Chronic Obstructive Pulmonary Disease 1-9 30.51 182.11 72.24 10-19 4.33 25.87 239.55 79.79 20 0.79 48.71 318.75 112.30 21-39 1.40 49.89 384.47 116.31 40+ 66.29 466.72 149.06 Combined 1.32 45.90 295.70 100.71 All-Cause Mortality 1-9 281.91 1,190.41 4,702.79 1,971.17 10-19 341.35 1,445.34 5,387.83 2,319.19 20 417.24 1,697.89 5,849.46 2,499.91 21-39 429.12 1,823.46 6,511.74 2,710.34 40+ 586.29 2,195.01 6,910.57 2,966.77 Combined 422.43 1,715.30 5,756.71 2,465.47 a Rates adjusted within 15-year group by 5-year age-specific rates to 1980 U.S. standard population. All-ages rate adjusted by 5-year age-specific rates to 1980 U.S. standard population older than 30 years of age. Age 123

Smoking and Tobacco Control Monograph No. 8 Table 6 Mortality rates among white female current smokers, by level of cigarette consumption standardized absolute mortality rates per 100,000 a Cigarettes Per Day 35-49 50-64 65-79 All Ages Lung Cancer 1-9 1.79 11.15 27.46 8.81 10-19 3.71 26.72 71.26 26.07 20 14.36 49.57 132.39 49.07 21-39 28.13 89.17 281.21 164.49 40+ 20.86 119.01 208.39 79.37 Combined 9.90 37.92 84.76 33.61 Coronary Heart Disease 1-9 15.36 106.14 741.69 331.19 10-19 22.58 174.20 1,075.58 457.27 20 24.26 206.90 1,060.19 450.07 21-39 42.26 220.24 1,301.99 561.03 40+ 35.25 272.41 790.83 438.95 Combined 24.05 173.61 958.01 411.82 Cerebrovascular Disease 1-9 9.67 44.21 320.71 153.70 10-19 15.48 76.58 362.93 185.36 20 18.74 76.30 430.75 191.77 21-39 19.44 70.22 542.96 200.22 40+ 20.86 120.03 579.24 146.39 Combined 15.75 69.02 375.14 176.39 Chronic Obstructive Pulmonary Disease 1-9 0.89 3.89 15.61 7.23 10-19 1.00 8.34 64.75 19.57 20 1.60 17.43 102.95 25.72 21-39 1.02 15.24 154.11 58.60 40+ 3.04 31.54 189.02 44.30 Combined 1.24 11.21 62.17 18.85 All-Cause Mortality 1-9 150.17 556.24 2,278.22 1,073.12 10-19 195.82 743.52 2,773.20 1,283.95 20 237.70 843.56 3,148.53 1,403.89 21-39 275.14 965.07 3,739.58 1,730.44 40+ 324.06 1,219.96 3,196.19 1,586.20 Combined 211.60 759.29 2,749.85 1,271.06 a Rates adjusted within 15-year group by 5-year age-specific rates to 1980 U.S. standard population. All-ages rate Age 124

Chapter 3 Table 7 Mortality rates among black male current smokers, by level of cigarette consumption standardized absolute mortality rates per 100,000 a Cigarettes Per Day 35-49 50-64 65-79 All Ages Lung Cancer 1-9 42.17 174.87 324.78 123.70 10-19 14.63 140.36 317.61 103.30 20 37.82 230.00 612.15 190.25 21-39 90.81 26.79 40+ 618.24 182.41 Combined 27.08 184.86 389.73 133.44 Coronary Heart Disease 1-9 86.80 542.86 1,542.04 794.07 10-19 43.88 637.54 1,384.31 690.06 20 157.79 607.03 1,718.76 735.12 21-39 79.21 800.24 2,920.68 787.25 40+ 372.28 109.84 Combined 91.36 601.71 1,515.39 740.87 Cerebrovascular Disease 1-9 86.80 348.13 1,074.99 464.84 10-19 176.20 816.90 198.96 20 104.59 212.68 865.73 391.66 21-39 199.50 58.86 40+ 1,616.46 290.82 Combined 53.49 236.85 918.86 353.53 Chronic Obstructive Pulmonary Disease 1-9 39.40 41.02 65.91 10-19 29.34 317.61 65.80 20 72.36 345.87 83.57 21-39 140.10 41.33 40+ 206.08 60.80 Combined 54.01 217.65 76.88 All-Cause Mortality 1-9 606.06 2,363.62 5,366.52 2,672.09 10-19 490.44 1,908.51 6,418.90 2,566.44 20 876.34 2,100.09 6,476.93 2,486.80 21-39 1,031.23 2,273.09 4,315.21 1,781.42 40+ 2,365.67 4,849.38 1,570.43 Combined 675.94 2,121.92 5,984.92 2,586.29 a Rates adjusted within 15-year group by 5-year age-specific rates to 1980 U.S. standard population. All-ages rate adjusted by 5-year age-specific rates to 1980 U.S. standard population older than 30 years. Age 125

Smoking and Tobacco Control Monograph No. 8 Table 8 Mortality rate ratios for black male current smokers, by level of cigarette consumption standardized rate ratios for black male current smokers compared with white male neversmokers a Cigarettes Per Day 35-49 50-64 65-79 All Ages Lung Cancer 1-9 15.72 14.86 8.78 7.83 10-19 5.45 11.93 8.59 6.54 20 14.10 19.54 16.55 12.05 21-39 7.72 1.70 40+ 52.52 11.55 Combined 10.09 15.71 10.53 8.45 Coronary Heart Disease 1-9 2.09 1.54 1.03 1.29 10-19 1.05 1.81 0.92 1.12 20+ 3.79 1.72 1.14 1.20 21-39 1.90 2.27 1.94 1.28 40+ 1.06 0.18 Combined 2.20 1.71 1.01 1.21 Cerebrovascular Disease 1-9 15.49 7.55 2.42 2.18 10-19 3.82 1.84 0.93 20 18.66 4.61 1.95 1.84 21-39 4.33 0.28 40+ 3.64 1.37 Combined 9.54 5.14 2.07 1.66 Chronic Obstructive Pulmonary Disease 1-9 9.54 1.79 7.17 10-19 7.10 13.83 7.15 20 17.52 15.06 9.09 21-39 33.92 4.49 40+ 49.89 6.61 Combined 13.08 9.48 8.36 All-Cause Mortality 1-9 3.32 3.01 1.55 1.73 10-19 2.68 2.43 1.85 1.66 20 4.80 2.68 1.87 1.61 21-39 5.64 2.90 1.25 1.15 40+ 3.02 1.40 1.02 Combined 3.70 2.70 1.73 1.67 a Rates adjusted within 15-year group by 5-year age-specific rates to 1980 U.S. standard population. All-ages rate adjusted by 5-year age-specific rates to 1980 U.S. standard population older than 30 years of age. Age 126

Chapter 3 Table 9 Mortality rates among black female current smokers, by level of cigarette consumption standardized absolute mortality rates per 100,000 a Cigarettes Per Day 35-49 50-64 65-79 All Ages Lung Cancer 1-9 15.19 39.16 11.53 10-19 12.89 92.65 86.36 47.05 20 21-39 40+ 668.43 197.22 Combined 3.80 42.33 45.56 21.92 Coronary Heart Disease 1-9 55.13 264.00 938.90 460.68 10-19 55.72 319.15 663.17 231.54 20 28.31 271.87 330.63 148.87 21-39 751.63 221.76 40+ 1,336.87 394.43 Combined 49.51 301.68 781.49 391.50 Cerebrovascular Disease 1-9 19.11 160.91 516.85 177.06 10-19 61.04 159.70 153.94 196.92 20 28.31 473.79 94.42 21-39 775.80 251.58 40+ Combined 46.80 129.35 429.88 170.34 Chronic Obstructive Pulmonary Disease 1-9 15.19 4.48 10-19 20 21-39 40+ Combined 8.22 2.43 All-Cause Mortality 1-9 319.48 1,004.55 3,438.59 1,576.38 10-19 393.11 1,380.88 1,671.75 937.97 20 421.01 822.07 3,842.67 1,070.41 21-39 775.80 1,343.00 647.82 40+ 2,005.30 591.65 Combined 364.45 1,098.49 3,076.47 1,419.34 a Rates adjusted within 15-year group by 5-year age-specific rates to 1980 U.S. standard population. All-ages rate adjusted by 5-year age-specific rates to 1980 U.S. standard population older than 30 years of age. Age 127

Smoking and Tobacco Control Monograph No. 8 Table 10 Mortality rate ratios for black female current smokers, by level of cigarette consumption standardized rate ratios for black female current smokers compared with white female never-smokers a Cigarettes Per Day 35-49 50-64 65-79 All Ages Lung Cancer 1-9 1.79 1.68 1.20 10-19 7.86 10.89 3.71 4.89 20 21-39 40+ 78.55 20.48 Combined 2.32 4.97 1.96 2.28 Coronary Heart Disease 1-9 7.15 3.20 1.37 1.49 10-19 7.22 3.87 0.96 0.75 20 3.67 3.30 0.48 0.48 21-39 9.12 0.72 40+ 16.23 1.27 Combined 6.42 3.66 1.14 1.26 Cerebrovascular Disease 1-9 3.15 5.14 1.73 1.07 10-19 10.07 5.10 0.52 1.19 20 4.67 1.59 0.57 21-39 127.92 1.52 40+ Combined 7.72 4.13 1.44 1.03 Chronic Obstructive Pulmonary Disease 1-9 10.50 1.17 10-19 20 21-39 40+ Combined 5.68 0.63 All-Cause Mortality 1-9 2.12 2.08 1.64 1.50 10-19 2.61 2.86 0.80 0.89 20 2.79 1.70 1.84 1.02 21-39 5.15 2.78 0.62 40+ 4.15 0.56 Combined 2.42 2.27 1.47 1.35 a Rates adjusted within 15-year group by 5-year age-specific rates to 1980 U.S. standard population. All-ages rate adjusted by 5-year age-specific rates to 1980 U.S. standard population older than 30 years of age. Age 128

Chapter 3 for each age interval as well as the fitted values for each type of regression, all weighted to the square root of PMO's, for white males and females for lung cancer, CHD, CVD, COPD, and all-cause mortality. Number of deaths and PMO's were tabulated for current smokers, with breakdowns along dimensions of age of initiation of smoking, duration of smoking, number of cigarettes smoked per day, and attained age. The difference between age of initiation and current monthly age was used to calculate duration of smoking for current smokers. RESULTS All-cause mortality risk due to smoking changes with the age of the smoker. A long time lag exists between beginning Changes in the Risk smoking and onset of an increase in risk, and the biologic of Smoking With Age changes induced by smoking over time are cumulative in their effect on mortality. Smoking-related increased risk is commonly expressed as a ratio of the mortality rate in smokers compared with that of never-smokers (rate ratio), and a single summary rate ratio for smoking often is presented derived across all categories of smokers. However, the mortality rate in never-smokers changes with age, and the difference in mortality rates between smokers and never-smokers also changes with age. As a result, rate ratios for smoking are not constant across all age groups. The absolute magnitude of the excess mortality rate among smokers required to produce a rate ratio of two is much larger at age 80 than it is at age 40. Understanding changes in smoking risk with age requires an appreciation of both change in rate ratio with age and change in excess mortality rates with age. Figure 1 presents age-specific rate ratios for all-cause mortality for white male cigarette smokers in contrast to the absolute difference in mortality rates between smokers and never-smokers of the same ages. Rate ratios for all-cause mortality peak at 2.66 among the 45- to 49-year-old age group and then decline steadily with further increases in age. Differences between smoker and never-smoker mortality rates increase steadily with age and are greatest for that age group with the lowest rate ratio (age 85 and older). The inference that might be drawn from the rate ratio data alone that the impact of smoking on mortality declines at older ages would be incorrect, or at least incomplete. The impact of smoking on absolute, as opposed to relative, mortality continues to grow with age. A similar effect is noted when rate ratios and excess mortality rates for white males are presented for four major causes of death linked to cigarette smoking (Figures 2 and 3). Rate ratios for lung cancer and COPD are much higher than those for CHD and CVD because of the multiplicity of other etiologic factors for vascular disease, in contrast to the relative specificity of cigarette smoking as a cause of lung cancer and COPD. There is a decline in rate ratio for all these causes of death among older age groups. The age at which an increased rate ratio is first manifest is not the same for each cause of death. The rate ratio for CHD increases by the mid- to late- 30-year-old age group, peaks with the 40- to 44-year-old age group, and then 129

Smoking and Tobacco Control Monograph No. 8 Figure 1 White male age-specific all-cause rate ratio and excess mortality between smokers and never-smokers Rate Ratio 2.8 2.6 2.4 2.2 2.0 1.8 1.6 1.4 1.2 1.0 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Age Group 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 0 Difference in Smoker and Nonsmoker Death Rates declines. An increased risk for lung cancer is first evident in the mid- to late- 40-year-old age group, and an increased rate ratio for death from COPD is not evident until the late 50-year-old age group. This pattern is more evident when the differences between smoker and never-smoker mortality rates are examined (Figure 3). The impact of smoking on excess mortality prior to age 60 is largely manifest through its effect on deaths from CHD. Between ages 60 to 70 years, excess lung cancer mortality first increases rapidly, followed by a rapid increase in excess COPD mortality during the next decade of life. After age 80, each of these disease processes make an equivalent contribution to excess mortality. Thus, excess cause-specific mortality and all-cause mortality increase with age, but the fraction of excess all-cause mortality attributable to CHD is greater at younger ages. Tables 11 through 14 present 5-year age-specific smoking risks by level of cigarette consumption per day for white males and females. Risks are presented as rate ratios (Tables 11 and 13) and as excess mortality rates, and the difference in mortality rates is presented between smokers and neversmokers (Tables 12 and 14). Risks are presented for each of four causes of death and for all-cause mortality. Never-smoker rates used in these tables are observed age-specific rates. Tables 5 to 7 and 9 present age- and causespecific death rates for smokers of specified numbers of cigarettes per day. Fifteen-year age groups are presented for whites and blacks of both genders to allow comparison across race and gender of actual death rates for smokers in each stratum of age and number of cigarettes smoked per day. Rates were adjusted within 15-year age groups by 5-year age-specific rates to the U.S. 1980 standard population, but no attempt was made to adjust for differences in duration of smoking across strata or within strata for the different race and 130

Chapter 3 Figure 2 White male cause-specific rate ratios for smoking by age 20 18 16 14 Rate Ratio 12 10 8 6 4 2 0 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Age Group 65-69 70-74 75-79 80-84 85+ Lung cancer Coronary heart disease Cerebrovascular disease Chronic obstructive pulmonary disease gender groups. Fifteen-year age groups were used because of the small number of deaths occurring among blacks for some of the causes of death. In general, the small numbers of deaths among black never-smokers for many of the causes of death preclude generation of black-specific rate ratios. For example, there were only two lung cancer deaths among black male never-smokers. However, Tables 8 and 10 present rate ratios for black males and females by cause of death and all-cause mortality using the death rates among black smokers compared with the death rates among white neversmokers. These rate ratios allow rough comparison of the rate ratios for blacks by number of cigarettes smoked per day but should be interpreted with caution because of the small number of deaths among black smokers and the likely confounding of age and duration of smoking in these crossrace comparisons. White Males Rate ratios for all-cause mortality among white males increase Tables 5, 11, and 12 with increasing number of cigarettes smoked per day and are higher at younger ages (45 to 54). Death rates for never-smokers are also 131

Smoking and Tobacco Control Monograph No. 8 Figure 3 White male cause-specific excess mortality for smoking by age 1,400 Difference Between Smoker and Nonsmoker Death Rates 1,200 1,000 800 600 400 200 0 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Age Group 65-69 70-74 75-79 80-84 85+ Lung cancer Coronary heart disease Cerebrovascular disease Chronic obstructive pulmonary disease lower at younger ages, particularly for those diseases for which smoking causes most of the disease occurrence (lung cancer and COPD). A low death rate among never-smokers can produce a large rate ratio for smokers even if the actual death rates among smokers are modest. This effect is manifest among white males by high rate ratios for lung cancer and COPD at younger ages despite low excess death rates for these diseases. In contrast, the largest contribution to excess mortality among smokers at younger ages results from CHD even though the rate ratios for CHD are much lower than those for lung cancer. This seeming discordance between rate ratios and excess mortality is the result of the relatively high death rates from CHD among never-smokers, and these higher CHD death rates in never-smokers occur because several factors other than smoking (e.g., hypertension, elevated cholesterol) make substantial causal contributions to CHD death rates. Rate ratios for all-cause mortality and for disease-specific mortality decline among white males at older ages; however, the excess mortality rates among smokers for lung cancer, CHD, and COPD become similar in magnitude as age increases (Table 12). Increased rate ratios for CVD are evident at younger ages, but there is an inconsistent dose-response relationship, possibly caused by low rates of death from this cause at these ages. Rate ratios approach 1 among the older age groups, and there is no clear dose-response relationship with the summary rate ratios standardized to the U.S. 1980 population. Excess mortality rates among smokers for CVD rise only modestly with age. 132

Table 11 Age-specific rate ratios for white male current smokers, by level of cigarette consumption Age Chapter 3 Cigarettes Per Day 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ US80 a Lung Cancer 1-9 9.75 3.85 3.19 4.65 3.58 4.80 5.41 1.49 3.54 3.74 10-19 2.45 8.90 6.00 8.00 10.69 7.94 11.85 10.41 3.75 5.27 7.75 20 3.82 21.40 11.58 13.02 15.11 12.96 16.16 14.60 9.41 4.81 11.76 21-39 5.18 18.85 18.91 15.88 20.44 18.54 25.90 19.97 14.72 8.21 17.02 40+ 7.10 23.82 16.88 23.18 26.35 21.41 23.22 27.62 16.76 9.44 19.97 Combined 4.15 18.43 12.77 13.60 16.05 12.82 15.41 12.84 6.47 4.79 11.14 Coronary Heart Disease 1-9 2.07 3.20 2.27 1.68 1.70 1.41 1.35 1.16 1.21 1.01 1.16 1.25 10-19 3.09 3.43 3.51 2.40 2.16 1.65 1.57 1.45 1.21 1.25 1.11 1.45 20 3.20 5.63 3.67 3.07 2.27 1.82 1.64 1.52 1.27 1.29 1.36 1.58 21-39 2.46 5.92 3.88 3.12 2.17 1.83 1.65 1.62 1.21 1.31 1.15 1.57 40+ 5.12 9.66 4.45 3.57 2.75 2.12 1.78 1.61 1.45 1.53 1.51 1.84 Combined 3.15 5.73 3.73 2.97 2.26 1.79 1.61 1.47 1.25 1.22 1.21 1.53 Cerebrovascular Disease 1-9 2.13 2.78 1.56 1.62 1.75 1.35 1.03 1.40 0.93 1.07 1.16 10-19 2.45 3.63 1.13 1.75 1.76 1.58 1.34 1.15 1.01 1.25 1.26 20 2.54 3.41 1.68 2.19 2.06 1.73 1.26 1.11 1.12 0.90 1.18 21-39 3.46 4.09 2.36 2.25 2.30 1.72 1.39 1.11 0.82 1.04 1.20 40+ 1.89 3.02 2.62 3.22 2.60 1.77 1.43 1.36 1.60 0.68 1.33 Combined 2.64 3.51 1.92 2.24 2.10 1.66 1.28 1.18 1.05 1.07 1.24 133

134 Table 11 (continued) Cigarettes Per Day 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ US80 a Chronic Obstructive Pulmonary Disease 1-9 11.48 9.93 7.03 14.20 5.00 11.01 6.37 7.85 10-19 2.61 5.41 8.87 9.16 11.85 10.39 14.01 3.76 8.67 20 3.79 13.69 15.74 10.58 19.33 12.80 15.39 8.02 12.21 21-39 3.23 10.30 18.25 16.47 22.94 13.49 8.50 8.21 12.64 40+ 5.53 23.78 18.78 14.68 24.98 21.05 16.60 9.44 16.21 Combined 3.47 12.81 14.93 11.53 17.70 11.01 13.36 6.38 10.95 Age All-Cause Mortality 1-9 0.65 1.73 1.93 1.50 1.61 1.46 1.35 1.36 1.36 1.20 1.07 1.27 10-19 1.83 1.36 2.28 1.94 1.96 1.73 1.70 1.61 1.42 1.31 1.29 1.50 20 1.82 2.17 2.65 2.43 2.21 2.03 1.84 1.79 1.51 1.48 1.22 1.62 21-39 1.79 2.40 2.65 2.70 2.27 2.22 2.07 2.01 1.65 1.42 1.35 1.75 40+ 2.91 3.20 3.39 3.18 2.94 2.55 2.25 2.01 1.82 1.65 1.28 1.92 Combined 1.87 2.21 2.66 2.47 2.25 2.03 1.85 1.73 1.48 1.36 1.20 1.59 a Standardized to U.S. 1980 population by 5-year strata greater than 30 years of age. Smoking and Tobacco Control Monograph No. 8

Table 12 Age-specific excess mortality (rate difference) for white male current smokers, by level of cigarette consumption Age Chapter 3 Cigarettes Per Day 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ US80 a Lung Cancer 1-9 22.89 19.56 25.89 63.54 81.17 127.00 230.57 42.50 328.97 43.25 10-19 8.64 20.68 34.34 82.72 168.57 217.87 362.75 492.37 236.74 552.56 106.54 20 16.77 53.39 72.61 142.09 245.51 375.74 506.74 711.21 723.54 493.63 169.84 21-39 24.91 46.72 123.01 175.87 338.39 550.86 832.15 922.17 1,179.83 933.83 252.92 40+ 36.34 59.71 109.02 262.19 441.22 641.10 742.55 1,392.55 1,355.08 1,093.71 299.47 Combined 18.74 45.62 80.84 148.98 261.88 371.41 481.62 619.34 470.08 490.76 160.08 Coronary Heart Disease 1-9 20.36 65.55 104.60 114.39 227.41 242.52 333.75 248.57 525.22 27.22 1022.42 156.14 10-19 40.02 72.39 207.11 233.74 376.52 390.65 546.88 688.21 513.71 908.26 713.66 279.33 20 41.99 137.82 219.72 347.63 410.68 489.03 614.33 785.94 661.58 1,037.30 2,331.05 354.26 21-39 27.98 146.61 237.29 355.29 380.78 496.87 626.62 949.34 515.53 1,112.00 946.45 347.68 40+ 78.81 257.81 284.62 430.87 566.40 671.50 749.11 928.92 1,112.27 1,923.57 3,288.87 513.55 Combined 41.03 140.85 225.05 329.64 408.95 475.19 590.15 714.66 609.62 790.90 1,359.97 324.84 Cerebrovascular Disease 1-9 10.13 16.34 14.24 23.56 59.54 63.30 13.45 369.67-128.81 258.63 34.98 10-19 12.96 24.12 3.26 28.76 60.26 106.43 149.35 139.92 13.05 889.52 55.25 20 13.79 22.10 17.22 45.25 83.80 132.40 113.89 103.32 213.03-373.15 37.84 21-39 21.93 28.34 34.54 47.79 102.98 131.64 173.37 97.25-322.44 128.94 42.77 40+ 7.98 18.54 41.08 84.56 126.54 140.89 192.51 328.73 1,082.91-1,146.30 71.04 Combined 14.64 23.00 23.29 47.44 87.47 119.78 123.71 166.72 82.28 247.09 50.81 135

136 Table 12 (continued) Cigarettes Per Day 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ US80 a Chronic Obstructive Pulmonary Disease 1-9 28.17 58.93 87.79 234.34 183.23 496.49 695.78 63.04 10-19 5.52 11.86 51.95 118.72 192.71 429.74 645.51 357.68 70.59 20 9.57 34.11 97.28 139.46 325.50 540.03 713.66 909.07 103.10 21-39 7.67 24.97 113.91 225.20 389.57 571.42 372.33 933.83 107.12 40+ 15.56 61.19 117.35 199.19 425.66 917.47 773.86 1,093.71 139.86 Combined 8.46 31.74 91.99 153.29 296.42 457.97 613.11 697.52 91.51 Age All-Cause Mortality 1-9 -42.08 136.52 237.92 214.68 442.25 585.96 749.00 1,243.74 2,138.83 1,933.24 1,207.60 424.68 10-19 100.69 67.82 327.25 400.96 702.45 914.51 1,488.61 2,111.39 2,464.95 3,029.94 5,342.23 772.70 20 98.95 218.62 422.08 611.99 885.56 1,295.23 1,792.11 2,710.24 3,021.68 4,616.55 3,980.88 953.42 21-39 95.58 262.19 419.81 728.21 924.43 1,531.48 2,289.19 3,485.47 3,826.43 4,081.91 6,315.92 1,163.85 40+ 231.47 412.95 610.53 935.53 1,416.44 1,954.96 2,658.94 3,475.43 4,858.38 6,220.61 5,100.26 1,420.28 Combined 105.09 226.63 423.11 630.09 911.25 1,302.30 1,809.07 2,515.85 2,872.05 3,493.70 3,716.60 918.98 a Standardized to U.S. 1980 population by 5-year strata greater than 30 years of age. Smoking and Tobacco Control Monograph No. 8

Table 13 Age-specific rate ratios for white female current smokers, by level of cigarette consumption Age Chapter 3 Cigarettes Per Day 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ US80 a Lung Cancer 1-9 1.69 0.81 1.06 1.56 1.27 1.68 0.88 1.01 0.91 10-19 2.62 2.10 3.49 2.56 3.32 3.19 3.36 2.72 3.38 2.71 20 8.48 8.89 7.71 6.41 4.74 8.34 6.33 3.06 1.25 3.79 5.10 21-39 18.20 11.87 12.80 9.54 10.06 11.86 9.31 14.41 67.21 17.08 40+ 10.78 13.64 15.07 24.17 7.89 5.48 15.37 6.75 8.24 Combined 6.28 5.39 5.53 4.80 3.83 4.80 3.80 2.59 1.27 2.05 3.49 Coronary Heart Disease 1-9 9.20 0.68 1.89 1.59 1.41 1.17 1.06 1.07 1.09 1.18 0.91 1.07 10-19 7.37 2.36 2.72 2.63 2.43 1.85 1.77 1.55 1.47 1.33 1.22 1.48 20 3.63 3.24 3.81 2.96 2.02 1.86 1.78 1.21 1.19 1.20 1.45 21-39 19.48 5.82 3.59 4.16 2.91 2.25 1.79 1.91 1.93 1.54 1.57 1.81 40+ 6.47 4.02 4.34 3.87 2.82 1.86 1.18 0.78 0.57 1.71 1.42 Combined 6.53 2.90 2.83 2.96 2.43 1.77 1.58 1.45 1.26 1.23 1.06 1.33 Cerebrovascular Disease 1-9 2.30 1.69 1.26 1.49 1.45 1.36 0.98 1.30 0.98 0.89 0.69 0.93 10-19 5.53 1.31 2.33 2.58 2.41 2.42 1.63 1.09 1.15 1.05 0.87 1.12 20 3.42 2.73 3.23 2.91 2.44 2.25 1.86 1.40 1.32 1.03 0.77 1.16 21-39 4.87 0.91 4.26 3.14 2.11 1.97 1.29 1.19 2.39 0.73 0.62 1.21 40+ 2.69 5.30 4.23 4.30 3.43 1.96 1.17 2.40 0.88 Combined 3.81 1.86 2.67 2.54 2.21 2.07 1.48 1.25 1.18 0.95 0.75 1.06 137

138 Table 13 (continued) Cigarettes Per Day 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ US80 a Chronic Obstructive Pulmonary Disease 1-9 2.54 4.65 1.68 2.79 1.30 3.62 1.89 10-19 6.29 3.40 6.65 6.74 6.16 4.58 11.34 2.01 3.70 5.11 20 6.02 4.05 10.95 18.38 14.12 11.44 12.35 1.49 6.72 21-39 6.39 4.57 7.42 16.97 5.45 23.55 22.17 25.11 15.31 40+ 19.09 13.16 43.24 6.73 19.44 34.61 11.57 Combined 5.20 2.80 7.23 11.54 7.00 7.01 8.23 1.51 2.90 4.93 Age All-Cause Mortality 1-9 0.79 1.01 1.11 1.13 1.20 1.13 1.04 1.10 1.11 1.07 0.86 1.02 10-19 1.47 1.03 1.40 1.40 1.64 1.54 1.41 1.29 1.30 1.16 0.96 1.22 20 1.17 1.73 1.71 1.75 1.84 1.67 1.74 1.63 1.27 1.25 0.96 1.34 21-39 1.67 1.85 1.90 1.93 1.96 2.06 1.56 1.74 1.96 1.25 1.48 1.65 40+ 0.83 2.51 2.67 2.29 2.78 2.47 1.68 1.62 1.37 1.15 1.17 1.51 Combined 1.21 1.39 1.53 1.53 1.66 1.53 1.40 1.34 1.24 1.14 0.92 1.21 a Standardized to U.S. 1980 population by 5-year strata greater than 30 years of age. Smoking and Tobacco Control Monograph No. 8

Table 14 Age-specific excess mortality (rate difference) for white female current smokers, by level of cigarette consumption Age Chapter 3 Cigarettes Per Day 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ US80 a Lung Cancer 1-9 1.14-0.71 0.32 3.85 3.94 11.34-2.48 0.52-0.82 10-19 2.68 4.04 12.46 10.86 33.36 36.81 49.65 66.11 113.10 16.44 20 12.40 29.09 33.59 37.52 53.81 123.18 112.01 79.26 11.88 164.77 39.44 21-39 28.52 40.05 59.07 59.25 130.38 182.15 174.66 514.86 3,907.92 154.86 40+ 16.22 46.58 70.43 160.76 99.14 75.20 302.05 220.68 69.74 Combined 8.75 16.18 22.66 26.39 40.72 63.81 58.90 60.92 12.80 61.94 23.97 Coronary Heart Disease 1-9 11.80-2.69 13.28 17.32 27.69 26.69 21.27 50.53 119.09 421.16-435.41 21.51 10-19 9.17 11.25 25.85 48.25 96.27 137.26 265.62 378.22 625.83 762.21 1,130.82 147.60 20 21.84 33.62 83.11 131.50 164.55 299.76 534.54 276.20 444.43 998.12 140.39 21-39 26.61 39.99 38.82 93.28 128.16 200.77 274.82 622.77 1,224.47 1,226.77 2,889.48 251.36 40+ 45.34 45.31 98.71 192.69 292.97 297.02 125.97-284.21-975.03 3,588.69 129.28 Combined 7.96 15.78 27.46 58.00 95.86 124.47 200.49 308.87 343.81 534.95 318.32 102.14 Cerebrovascular Disease 1-9 3.74 4.56 2.43 8.77 11.34 19.54-2.21 81.72-15.71-154.32-1,001.90-12.24 10-19 13.03 2.05 12.61 28.18 35.66 76.21 79.24 23.83 96.61 66.24-414.21 19.41 20 6.96 11.45 21.18 34.14 36.55 67.33 107.42 111.29 209.21 47.15-731.29 25.82 21-39 11.15-0.60 30.90 38.21 28.24 52.03 36.72 51.00 901.14-374.91-1,209.50 34.28 40+ 11.24 40.79 57.58 83.66 130.72 120.36 47.94 906.45-19.55 Combined 8.09 5.73 15.86 27.42 30.74 57.70 60.19 69.50 118.65-63.65-814.11 10.45 139

140 Table 14 (continued) Cigarettes Per Day 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ US80 a Chronic Obstructive Pulmonary Disease 1-9 1.96 7.19 3.11 14.86 4.48 109.37 3.41 10-19 2.79 2.80 7.20 11.29 23.51 29.74 154.84 40.31 112.63 15.74 20 2.64 3.56 12.67 34.22 59.82 86.71 169.91 19.43 21.90 21-39 2.84 4.17 8.18 31.44 20.31 187.36 316.98 964.99 54.77 40+ 9.53 15.50 83.18 26.10 153.22 503.16 40.47 Combined 2.21 2.10 7.94 20.75 27.36 49.96 108.16 20.35 79.21 15.02 Age All-Cause Mortality 1-9 -21.35 1.34 23.91 41.64 87.38 92.58 44.13 214.02 404.33 490.61-2,026.40 22.59 10-19 47.72 4.36 84.93 129.08 280.45 389.08 496.21 587.89 1,149.69 1,116.98-517.04 233.43 20 17.30 109.32 151.47 244.61 369.14 484.22 890.65 1,295.42 1,018.92 1,725.55-620.83 353.36 21-39 67.52 127.80 192.80 301.71 419.22 762.73 671.52 1,511.79 3,625.62 1,705.75 7,098.13 679.91 40+ -17.31 225.59 358.70 421.11 777.79 1,055.52 817.63 1,268.50 1,393.41 1,057.78 2,546.14 535.67 Combined 21.45 59.01 112.76 171.32 287.53 384.15 487.15 700.73 907.02 964.11-1,172.10 220.54 a Standardized to U.S. 1980 population by 5-year strata greater than 30 years of age. Smoking and Tobacco Control Monograph No. 8

Chapter 3 White Females All-cause and cause-specific mortality rate ratios are generally Tables 6, 13, and 14 lower for white females than for white males. Excess mortality rates among smokers also are lower for each cause of death among white females compared to white males. The general pattern of dose-response relationships and change in risk with age is similar for white males and females once the difference in magnitude of risks is considered. Part of the difference between white males and white females in relative and excess mortality is attributable to differences in duration of smoking between males and females of the same age, particularly among the older age groups. Males began to smoke cigarettes in large numbers in the early part of this century, whereas females initiated smoking during the late 1930's and 1940's (see Chapter 2). Female smokers in CPS-I also smoked fewer cigarettes per day than male smokers, contributing to their lower age-specific rate ratios. Black Males Numbers of deaths and PMO's among black males were substantially Tables 7 and 8 smaller than those among whites of both genders. There were only two deaths from lung cancer and no deaths from COPD among black male never-smokers. Among black male smokers there were 62 deaths from lung cancer and 24 deaths from COPD. Mortality rates for black male smokers are presented for age groups where deaths occurred (Table 7). To allow some approximation of the risks occurring among black male smokers, white male age-specific never-smoker death rates are compared with rates among black male smokers to generate rate ratio estimates (Table 8). The patterns seen in lung cancer and CHD rate ratios with number of cigarettes per day and age-specific changes in rate ratio are similar for black and white males. The absence of deaths from COPD among black male neversmokers precludes estimation of the rate ratios, but when white male neversmoker rates are used, an overall COPD rate ratio of 8.39 is calculated for black males compared with 10.96 among white males. No smoking-related increased risk for CVD is evident among black male smokers, and the increased risk demonstrated when white male never-smoker rates are used probably reflects the higher rates of CVD among all black males. Black Females Numbers of deaths and PMO's among black females were larger than Tables 9 and 10 those available for black males but were still substantially smaller than those for white males or females. Only modest increases in risks for lung cancer and CHD are demonstrable among black female smokers, and there does not appear to be an increased risk for CVD or all-cause mortality. There were too few deaths from COPD among black female smokers and never-smokers for meaningful estimation. Changes in the Risk Risks of smoking cigarettes have traditionally been expressed of Smoking With in relation to the age of the smoker, using age-specific Duration of Smoking rates for never-smokers as a comparison group. However, individuals begin smoking at different ages, and a given age group of smokers may contain individuals with markedly different durations of exposure. Therefore, categorizing disease risks by duration of smoking, rather than age, may be a more accurate method of examining this exposure. Tables 1 and 2 141